Kidney Week

Abstract: FR-PO1213

Comparative Effectiveness and Harms of Belatacept vs. Tacrolimus Among Kidney Transplant Recipients

Session Information

• Transplantation: Clinical - Rejection, Biomarkers, and Pharmacology
  October 23, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Transplantation

• 2002 Transplantation: Clinical

Authors

• Ismail, Sherin, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, United States

Sherin Ismail, PharmD, PhD, MPH

• Jonsson Funk, Michele, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, United States

Michele Jonsson Funk, PhD

• Flythe, Jennifer E., The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States

Jennifer E. Flythe, MD, MPH, FASN

• Edwards, Jessie K., The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, United States

Jessie K. Edwards, PhD

• Stürmer, Til, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, United States

Til Stürmer

• Kotzen, Elizabeth, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States

Elizabeth Kotzen, MD, MSc

• Mayo-Wilson, Evan, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, United States

Evan Mayo-Wilson

Background

Few studies have compared the effectiveness and harms of initiating belatacept versus tacrolimus for immunosuppression among kidney transplant recipients.

Methods

We conducted a cohort study emulating a target trial using data from the United States Renal Data System and the Scientific Registry of Transplant Recipients. We included adult Medicare beneficiaries (≥18 years) who underwent first kidney transplantation from 2012-2020 and initiated belatacept or tacrolimus at the time of transplant (intention-to-treat analysis).
Effectiveness outcomes included a primary composite (death or graft failure), rejection and kidney function assessed using estimated glomerular filtration rate (eGFR, mL/min/1.73 m²) at 2 years. Harm outcomes included post-transplantation diabetes mellitus, cardiac ischemic events (composite of acute myocardial infarction or revascularization procedures), post-transplantation lymphoproliferative disorders (PTLD), and mortality at 2 years. We standardized tacrolimus initiators to belatacept initiators using propensity score-derived weights. For all outcomes except mortality and eGFR, we estimated adjusted risk differences using weighted Aalen-Johansen estimators. For mortality, we used weighted Kaplan-Meier estimators. For eGFR, we used generalized estimating equations.

Results

We included 30,678 recipients, 870 initiating belatacept and 29,808 initiating tacrolimus. At 2 years, there was no evidence of between-group differences for the primary composite outcome (Table 1). Compared with tacrolimus initiators, belatacept initiators had a higher risk of rejection, lower incidence of post-transplantation diabetes mellitus, and higher incidence of PTLD. There was no evidence of difference in cardiac ischemic events or mortality between the two groups (Table 1).

Conclusion

Our findings provide real-world evidence on the comparative effectiveness and harms of belatacept versus tacrolimus initiation among kidney transplant recipients and may inform clinician-patient shared decision-making when selecting maintenance immunosuppression.